James Markin recently wound up in a local emergency room, after waking up at 2 a.m. with a severe headache and finding no relief from painkillers he had at home.
With emergency care clinics closed at that hour, the Sylvania Township resident headed — while in pain — to nearby ProMedica Flower Hospital.
“I spent a total of 20 minutes in the room — 10 of that waiting for a nurse and doctor to come. They took my blood pressure and temperature. It didn’t take the doctor long to figure out it was a tooth infection. They told me to go see a dentist,” Mr. Markin, 68, said.
He was shocked, however, when he received the service bill, $1,100 for less than an hour in the emergency room. Mr. Markin, a former letter carrier for the U.S. Postal Service, has federal health insurance. His insurance company negotiated a lower rate, which cut the bill in half. Still, he had to pay $595.35 out-of-pocket for that toothache.
Mr. Markin said he called Flower Hospital’s billing department and asked why a relatively minor problem was considered a Level 3 E.R. visit.
“You’re basically paying because of the equipment and everything that is available to use — even if you don’t use it,” he said he was told.
“I think the cost should be based on what you actually received, not what’s available. The way they charge has got to be changed,” he said.
Mr. Markin was one of many area residents who reached out to The Blade with details about health-care billing after learning that the area’s three hospital systems — Mercy, ProMedica, and the University of Toledo Medical Center, the former Medical College of Ohio — would not release exact costs for procedures. The hospitals later shared what they call “chargemaster” fees, or list prices, which can often be remotely related to what people pay.
Citing patient privacy laws, ProMedica officials said they could not comment specifically on Mr. Markin’s situation. But they said there is a set protocol for how patients are determined to be levels 1 to 5 in each emergency room in ProMedica. Level one is the lowest, with level 5 being the most severe cases.
“Something is going to be done on every patient that walks in the door. There will be some some kind of specimen. There is a list of rules of things that have to be done because they walked into the E.R.,” said Cynthia Kreiner, administrative director of reimbursements at ProMedica.
Bigger firms, bills
Maumee resident Mary Zielinski, 61, is frustrated by what she described as an unexplained and sudden increase in the cost of her rehabilitation therapy earlier this year. Mrs. Zielinski, who works in the pricing department for Kmart, had shoulder surgery in November and started going to therapy twice a week at Toledo Orthopedic Surgeons. She was charged about $149 for each session in November in December.
“I had decided pretty early on that despite the fact that the more therapy, the better, I just couldn't afford it, mostly due to the fact that it was a new year and my deductible started over. So I only went three times in January, and then I stopped going, which turned out to be a blessing in disguise,” she said.
The business was sold to ProMedica, and in January, it became ProMedica Toledo Rehab. The price of each therapy session increased dramatically from $149 to $456 a visit, Mrs. Zielinski said.
She called the billing department at ProMedica to express her frustration. “I told her: I said you should be ashamed, and ProMedica should be ashamed of themselves for charging that kind of a fee, and I did hang up. I was mad. I was very mad,” she said.
ProMedica officials would not comment on the specifics of Mrs. Zielinski’s situation.
“We don’t have the specifics of what they were charging before they joined ProMedica,” said Jered Wilson, vice president of managed-care contracts for the hospital system.
“When the rehab became part of ProMedica, we applied our common metro chargemasters charges to that,” he said.
Dr. Ian S. Elliot, president of the Toledo Clinic physicians group, whose business competes directly with ProMedica and other hospital systems, said what Mrs. Zielinski experienced is becoming common nationwide.
Physicians and other health-care providers have learned they can demand higher fees from the federal government and from private insurance companies if they are affiliated with a large hospital system such as Mercy or ProMedica.
Mrs. Zielinski said she went to the same office in the ProMedica Wildwood complex on Reynolds Road, and she saw the same therapist. The only thing that changed was the price of the service and the name on the door.
“This is part of what’s driving doctors out of independent practice. They can make more money if they become part [of] the systems,” Dr. Elliot said.
ProMedica is the largest system of hospitals and physicians in the Toledo area.
The hospital has been involved in a lengthy battle with the FTC over its acquisition of St. Luke’s Hospital in 2010.
That case’s judge, Raymond Kethledge of the U.S. 6th Circuit Court of Appeals, noted in court documents that ProMedica has a great deal of leverage in negotiating with insurance companies to set reimbursement rates.
The addition of St. Luke’s to its group would give it even more clout, and “the merger would allow ProMedica to unilaterally increase its prices above competitive levels,” he said.
The FCC is arguing it would give the health-care system too much power. The case was appealed and is pending in the court of appeals.
Savvier patients
Dr. Elliot, who started a debate over the price of health care in Toledo by advertising and comparing the cost of services at Toledo Clinic with area hospitals, said consumers are paying more attention to price now, as even those with private health insurance are increasingly being asked to pay more through co-pays and deductibles.
Health-care spending grew more slowly than the U.S. economy from 2010 to 2012, according to a recent report by the federal Centers for Medicare and Medicaid Services published by the journal Health Affairs. At the same time, the cost has shifted to employers. Premiums for employers rose 131 percent in the last decade. Annual premiums for employer-sponsored family health coverage reached $16,351 in 2013, up 4 percent from 2012. Workers on average are paying $4,565 toward the cost of their coverage, according to the Kaiser Family Foundation 2013 Employer Health Benefits Survey.
“Patients are getting more engaged in the process of making choices, driven by rising deductibles, now creeping up to $1,000 or $1,200. That’s a lot of money that is now coming right out of people’s pockets, and they are asking more questions,” said Richard Gundling, vice president of heath-care financial management for Kaiser.
This desire to find the best price for nonemergency procedures has given rise to new businesses such as consumer-oriented websites, where patients can type in their ZIP Codes and get estimates on the cost of a select group of medical procedures in their area.
Brad Niles, vice president of consumer engagement for one of those websites, newchoicehealth.com, said the site allows consumers to get a pretty good idea about the price for a procedure in their health-care market, “but getting an exact specific cost is the hard part,” he said.
“We are trying to demystify the chargemaster,” he said. “We knew for the most part that charges were a strong indicator for the consumer, but we have moved to price ranges because we are trying to get closer to what are patients likely to pay out of pocket.”
Toledo-area hospital officials said they could not disclose to The Blade what consumers with private insurance would likely pay for medical procedures because that information is proprietary and would put them at a competitive disadvantage with other health providers in the local market.
When asked how he is able to obtain the information to provide price-range estimates on his website, Mr. Niles said his company has developed a proprietary system that uses a unique algorithm to access data.
The website, which launched in 2009, has 100,000 unique visits each month, he said.
Mr. Niles and Mr. Gundling said many hospitals are reacting slowly to the desire from consumers to have more transparency in pricing and details about their out-of-pocket costs.
Executives at all local hospital systems said they are in the process of developing some sort of internal system — such as a hotline — to help consumers price shop.
There are some hospitals in larger cities, with more resources, that are doing it right, Mr. Gundling said. But all hospitals, large or small, are being pushed by consumers to provide more information, he said.
“This kind of giving an estimate is fairly new for hospitals in the retail environment,” he said. “So what can be perceived as hesitancy, it’s really about setting the expectations for patients.”
Contact Marlene Harris-Taylor at mtaylor@theblade.com or 419-724-6091.
First Published April 12, 2015, 4:00 a.m.
